The Royal Australian College of General Practitioners 2
• Discussingchoicesaroundpreferredplaceofcareduringtheirillnessandinthe‘terminalphase’
• Documentingthesediscussionsinaneasilyretrievableformat,heldbythepatient,theirSubstituteDecisionMaker,their
family and GP.
All of the above components can be strengthened if the patient’s primary carers and family are involved in some way.
Although state and territory government laws vary on ACP and ACDs, Advance Health Directives in some form are legally
binding documents in every state/territory of Australia. It is worth GPs familiarising themselves with some of the forms used
intheirstateorterritory.TheRACGPwebsiteprovideslinkstostate-basedresources:www.racgp.org.au/guidelines/
advancecareplans.
4. The vital role of general practice
GPs should aim to incorporate ACP as part of routine healthcare. A conversation about ACP ts well with a GP’s
responsibility to ensure that the patient receives, and understands, advice on various healthcare options relevant to any
current diagnosis and realistic assessment of prognosis.
GPs should consider raising the topic with all older patients. For example, when they attend for their over 75 year health
check, when dementia is suspected, those with life-threatening, complex and chronic illnesses and those patients with
terminal illness. In doing so, the GP should be mindful of the competency and mood of the patient and ensure that the
patient understands the purposes of ACP and an ACD and how it will be used in the future. Although encouraging their
patientstoengageinACP,GPsshouldmakeitclearthatdocumentingwishesinanACDisnotarequirement.TheGP
should however, also ensure that the patient understands that documented wishes, that are witnessed, have more legal
certainty than those that are only made verbally.
InitiatingaconversationaboutACPwhichfocusesonoutcomessuchaslifegoals,valuesandqualityoflifebeliefs,rather
than detailing types of treatment options a patient consents to or refuses, is likely to be more constructive. For example,
encourage patients to talk about and record in their ACDs the situations they would like to avoid, personal circumstances
and level of functioning considered acceptable or intolerable, interventions that they may consider to be overly intrusive or
their preference for palliative care. ACDs that follow this structure are more likely to be useful as a guide to help clinicians
apply patients’ wishes to future medical care. Some patients, however, may want to record specic detailed wishes of the
care and treatment they wish to receive, or not receive, under certain circumstances, and if so, they should be supported
to do this.
GPs should encourage patients to have conversations with their family, carers and other health professionals involved
in their care, to make them aware of their wishes and the existence of an ACD, if there is one. This will help avoid future
misunderstanding or family disagreements. A copy of an ACD should be included in medical les and be available to
accompany patients across healthcare settings.
ACP will often involve ongoing conversations between a GP and a patient and their selected Substitute Decision Maker(s).
It may be something a GP and their patient will return to and discuss and update regularly over many years, and may not
end with the signing of a legally recognised document such as an Advance Care Directive. On occasion, GPs may be asked
to witness an ACD they have not instigated. Whilst GPs are not under any obligation to do so, if the GP is condent the
person is competent and understands their ACD, a GP’s signature can improve condence in the document and ultimately
help ensure a patient’s wishes are followed.
5. More information
TheRACGPwebsite,undertheClinicalResourcestab,provideslinkstoallstateandterritoryspecicinformationand
resources: www.racgp.org.au/guidelines/advancecareplans. Links are also provided to training and development
resources produced by other organisations, including the UK’s Gold Standard Framework Centre’s guidance for clinicians to
support earlier recognition of patients nearing the end of life.
i
Maria J. Silveira, Scott Y.H. Kim, and Kenneth M. Langa. Advance Directives and Outcomes of Surrogate Decision Making before Death. N Engl J Med 2010;
362:1211-1218 April
ii
DeteringKM,HancockAD,ReadeMC,SilvesterW.Theimpactofadvancecareplanningonendoflifecareinelderlypatients:randomisedcontrolledtrial.BMJ. 2010
Mar 23;340:c1345. doi: 10.1136/bmj.c1345
iii
RheeJ,ZwarN,LynnA.UptakeandimplementationofAdvanceCarePlanninginAustralia:ndingsofkeyinformantinterviews.Australian Health Review; 36(1)
98-104. Published: 9 February 2012
iv
DeteringKM,HancockAD,ReadeMC,SilvesterW.Theimpactofadvancecareplanningonendoflifecareinelderlypatients:randomisedcontrolledtrial. BMJ. 2010
Mar 23;340:c1345. doi: 10.1136/bmj.c1345
v
CommonwealthofAustralia.AHealthierFutureForAllAustralians-FinalReportoftheNationalHealthandHospitalsReformCommission-June2009
vi
Darvall L, McMahon M, Piterman L. Medico-legal knowledge of general practitioners: disjunctions, errors and uncertainties. Journal of Law and Medicine. 2001;9(2):167-84
vii
CommonwealthParliamentofAustralia.Olderpeopleandthelaw.ReportoftheHouseofRepresentativesStandingCommitteeonLegalandConstitutionalAffairs,
InquiryintoOlderPeopleandtheLaw2007
viii
The Clinical T, and Ethical Principal Committee, of the Australian Health Ministers’ Advisory Council (AHMAC). A National Framework for Advance Care Directives.
Consultation Companion Guide for the Draft Framework. Draft ed. Canberra: AHMAC; 2010